Treatment of pyoderma gangrenosum: retrospective multicentre analysis of 121 patients

Analysis of clinical characteristics and factors affecting treatment responses in patients with pyoderma gangrenosum: a multicenter study of 239 patients☆

BACKGROUND

Pyoderma Gangrenosum (PG) is a chronic disease characterized by recalcitrant skin ulcers.

OBJECTIVE

We aimed to evaluate the demographic, clinical characteristics, treatments and factors affecting the treatment responses of patients with PG.

METHODS

We performed a multicenter study of 12 tertiary care centers. We analyzed the data of the patients who were followed up with a diagnosis of PG between the years 2012‒2022 retrospectively.

RESULTS

We included a total of 239 patients of whom 143 were female and 96 were male, with an average age of 54.2 ± 17.4 years. The most common treatment was systemic steroids (n = 181, 75.7%). Among these patients, 50.8% (n = 92) used systemic steroids as the sole systemic agent, while 49.2% (n = 89) used at least one adjuvant immunosuppressive agent. The independent factors determined in regression analysis to influence response to systemic steroids positively were disease onset age ≥ 30-years, negative pathergy, absence of leukocytosis, negative wound culture, presence of a single lesion, and absence of upper extremity involvement. Biological agents were used in 18.4% (n = 44) of the patients in the present study. We also analyzed pathergy positive PG and early onset (onset age < 30) PG separately due to their distinct clinical features which were revealed during statistical analysis.

STUDY LIMITATIONS

Retrospective nature of the present study.

CONCLUSIONS

Analyses of the factors influencing treatment responses are addressed in this study. Also, we concluded that investigation for accompanying autoinflammatory diseases of pathergy positive PG and early onset PG is necessary and the patients in these two groups are more resistant to treatment, necessitating more complicated treatments.

Pyoderma Gangrenosum: Treatment Options

Pyoderma gangrenosum is a rare neutrophilic dermatosis that leads to exceedingly painful ulcerations of the skin. Although the exact pathogenesis is not yet fully understood, various auto-inflammatory phenomena with increased neutrophil granulocyte activity have been demonstrated. Despite the limited understanding of the pathogenesis, it is no longer a diagnosis of exclusion, as it can now be made on the basis of validated scoring systems. However, therapy remains a major multidisciplinary challenge. Various immunosuppressive and immunomodulatory therapies are available for the treatment of affected patients. In addition, concomitant topical pharmacologic therapy, wound management and pain control should always be addressed. Corticosteroids and/or cyclosporine remain the systemic therapeutics of choice for most patients. However, in recent years, there has been an increasing number of studies on the positive effects of biologic therapies such as inhibitors of tumour necrosis factor-α; interleukin-1, interleukin-17, interleukin-23 or complement factor C5a. Biologics have now become the drug of choice in certain scenarios, particularly in patients with underlying inflammatory comorbidities, and are increasingly used at an early stage in the disease rather than in therapy refractory patients.

Clinical efficacy of flap transplantation combined with vacuum sealing drainage and methylprednisolone and cyclosporine in the treatment of pyoderma gangrenosum

This study was aimed to evaluate the clinical efficacy of flap transplantation combined with vacuum sealing drainage and methylprednisolone and cyclosporine in the treatment of ulcer wound of patients with pyoderma gangrenosum (PG). From August 2014 to February 2022, 30 patients with pyoderma gangrenosum ulcer wounds were selected as the research objects and randomly divided into the observation group (n = 12) and the control group (n = 18) in this retrospective study. The patients in observation group were treated with VSD combined with flap transplantation and immunosuppressive agent treatment, while the control group was treated with normal dressing change combined with hormone and cyclosporine. The ulcer wound healing time and dressing change times were compared between the two groups. All the 30 cases of two groups healed after corresponding treatment. The wound healing time of ulcer in the observation group was 35-40 days, with an average healing time of (35.83 ± 1.95) days, and the wound healing time of the control group was 60-200 days, with an average healing time of (44.14 ± 9.67) days. The healing time of observation groups was significantly shorter than that in the control group (t = 4.652, P < .05). The frequency of dressing change in the observation group was seven-eight times, with an average of (7.17 ± 0.39) times, and the frequency of dressing change in the control group was 75-86 times, with an average of (79.22 ± 3.62) times. The difference between the two groups was significant (t = 6.214, P < .05). The treatment of VSD combined with flap transplantation and immunosuppressive agent treatment promote ulcer wound healing of pyoderma gangrenosum.

Practical aspects of the diagnosis and management of pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare autoinflammatory ulcerative neutrophilic skin disease. Its clinical presentation is a rapidly progressing painful skin ulcer with ill-defined borders and surrounding erythema. The pathogenesis of PG is complex and not fully understood. Clinically, patients with PG often have various systemic diseases, the most common being inflammatory bowel disease (IBD) and arthritis. Due to the lack of specific biological markers, diagnosing PG remains difficult, which easily resulting in misdiagnosis. Some validated diagnostic criteria have been applied in clinical practice that facilitate its diagnosis. The treatment of PG currently consists mainly of immunosuppressive and immunomodulatory agents, especially biological agents, which have bright prospects for PG therapy. After the systemic inflammatory response is controlled, the problem of wounds becomes the main contradiction in PG treatment. Surgery is not controversial for PG, increasing evidence shows that with adequate systemic treatment, the benefits of reconstructive surgery for patients are increasing.

Atypical Forms of Pyoderma Gangrenosum in Inflammatory Bowel Disease: Report of Four Cases and Literature Review

Background

Cutaneous involvement is the second-most frequent extraintestinal manifestation of inflammatory bowel disease, with pyoderma gangrenosum (PG) a particularly relevant form because of its frequency, morbidity, and recurrence. The limited number of clinical trials involving PG increases the challenge to gastroenterologists in the management of this condition.

Case Presentation

Four cases of atypical presentations of PG are reported. A 25-year-old patient with ulcerative colitis presented an extensive chronic ulcerative lesion on her left leg that was associated with significant bleeding; the intestinal disease was in remission under the use of azathioprine. The patient was on long-term use of 60 mg corticosteroid with no improvement in the skin disease; however, initiation of cyclosporine induced remission. In the second case, a 52-year-old woman was a carrier of Crohn’s disease, with a history of partial colectomy. The patient’s skin condition had evolved with a cutaneous lesion localized in the perineal region, buttocks, and colostomy pouch, simulating a case of impetigo, and this had been treated with antibiotic cycles without improvement. Lesion biopsy suggested a diagnosis of PG. Consequently, the patient was started on biological therapy with infliximab, and the PG regressed. In the third case, a 38-year-old woman with a history of pancolitis presented a picture of PG with an extensive and deep ulcerative lesion in the right breast. The lesion regressed after treatment with oral corticosteroid. The final case was a 44-year-old woman with Crohn’s disease suffering from Crohn’s disease pancolitis. The patient’s condition evolved with a mixed pattern with pustules, bullae, and ulcerative lesions in the vulva, oral cavity, gluteus, right auricular region, scalp, and left flank, and was resolved by administration of adalimumab.

Conclusion

PG is an important and frequent manifestation of inflammatory bowel disease, with a spectrum of clinical variants, significant morbidity, and requiring a variety of therapeutic approaches.

Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments

Pyoderma gangrenosum is a rare inflammatory skin disease classified within the group of neutrophilic dermatoses and clinically characterized by painful, rapidly evolving cutaneous ulcers with undermined, irregular, erythematous-violaceous edges. Pyoderma gangrenosum pathogenesis is complex and involves a profound dysregulation of components of both innate and adaptive immunity in genetically predisposed individuals, with the follicular unit increasingly recognized as the putative initial target. T helper 17/T helper 1-skewed inflammation and exaggerated inflammasome activation lead to a dysregulated neutrophil-dominant milieu with high levels of tumor necrosis factor-α, interleukin (IL)-1β, IL-1α, IL-8, IL-12, IL-15, IL-17, IL-23, and IL-36. Low-evidence studies and a lack of validated diagnostic and response criteria have hindered the discovery and validation of new effective treatments for pyoderma gangrenosum. We review established and emerging treatments for pyoderma gangrenosum. A therapeutic algorithm based on available evidence is also provided. For emerging treatments, we review target molecules and their role in the pathogenesis of pyoderma gangrenosum.

Multifocal Pyoderma Gangrenosum with an Underlying Hemophagocytic Lymphohistiocytosis: Case Report and the Review of the Literature

Pyoderma gangrenosum (PG) is an uncommon, serious, ulcerating skin disease of uncertain etiology. It manifests as a noninfectious, progressive necrosis of the skin characterized by sterile neutrophilic infiltrates. It seems to be a disorder of the immune system. PG is associated with certain underlying conditions in at least 50% of cases. Therefore, it is important to look carefully for comorbidities in every patient with PG and treat them adequately to improve the prognosis. Here, we demonstrate a 35-year-old man diagnosed with multifocal PG and hemophagocytic lymphohistiocytosis (HLH) with fatal outcome, despite combined, long-term, intensive dermatological and hematological treatment with high doses of steroids, cyclosporin, intravenous immunoglobulins (IVIG), HLH-2004 protocol with intravenously administered etoposide, and anakinra. This case is presented owing to the extremely rare coexistence of PG and HLH and the related diagnostic and therapeutic difficulties. It is also worth underlying that the diagnosis of HLH should perhaps be considered in the presence of a high percentage of double-negative T lymphocytes (DNTs) in flow cytometry, after excluding the diagnosis of lymphoma and leukemia. In this article we have also performed and present the critical literature review of local and systemic options in the management of PG lesions based on a detailed search of the PubMed database.

[An unusually painful leg ulcer in an 81-year-old patient: an interdisciplinary challenge]

An 81-year-old male patient with a history of peripheral arterial disease (PAD) was admitted to the authors' outpatient clinic with a painful lower leg ulcer. As the degree of PAD did not correspond to the clinical findings, multiple biopsies were taken from the base and edge of the ulcer. This resulted in the histopathological and clinical diagnosis of pyoderma gangrenosum (PG). Since PG is often associated with numerous underlying diseases, further thorough examinations were performed. A mass in the gastric antrum suspicious for malignancy was histopathologically identified as gastric cancer (signet ring cell carcinoma). The PG was successfully treated with cortisone p.o. and tacrolimus ointment. Since the cancer was locally limited, the patient underwent surgery involving gastric resection with D2 lymphadenectomy and gastrojejunostomy (Roux-en‑Y anastomosis).

Skin manifestations in spondyloarthritis

Spondyloarthritides (SpA) like psoriatic arthritis, axial spondyloarthritis/ankylosing spondylitis, reactive arthritis and inflammatory bowel disease (IBD)-associated SpA can present with characteristic skin manifestations. These SpA-associated skin disorders may precede joint involvement, reflect a loss of efficacy of a current systemic treatment or can even be treatment associated. Cutaneous manifestations in SpA not only add additional morbidity with physical impact but also impose a psychosocial burden on affected patients. Psoriasis (PsO) - the main skin disease in SpA - has a variety of clinical presentations, including plaque-type PsO, inverse PsO, guttate PsO, erythrodermic PsO, nail PsO and pustular types. SpA associated with IBD presents with neutrophilic and granulomatous skin disorders, including pyoderma gangrenosum, hidradenitis suppurativa and cutaneous Crohn's disease. Reactive arthritides has a favourable prognosis and may feature keratoderma blenorrhagicum or balanitis circinatum as typical skin manifestations. Immunologically, SpA-associated skin diseases share interleukin (IL)-17 and IL-23 dysregulation but show distinctive genetic and immunological profiles. Therefore, they vary in their treatment responses to targeted therapies with biologicals or small molecules. In this review, we highlight the clinical presentation of skin manifestations in SpA and discuss therapeutic approaches in this interdisciplinary field.

Infliximab treatment for large, multifocal, abdominal pyoderma gangrenosum associated with ulcerative colitis: A case report

Pyoderma gangrenosum is an uncommon neutrophilic dermatosis that is highly associated with pathergy in the setting of trauma or surgery, systemic disease, or may be idiopathic. Herein, we present the case of a 68-year-old female with ulcerative colitis who underwent a subtotal colectomy with an end-ileostomy and presented post-operatively with large, multifocal pyoderma gangrenosum at two abdominal sites. She was managed with intralesional triamcinolone injections and high-dose systemic steroids and was transitioned to IV infliximab. Our case report illustrates the role of infliximab in the treatment of complicated multifocal pyoderma gangrenosum and contemplates the impact of systemic infliximab exposure.

Negative Pressure Wound Therapy in Pyoderma Gangrenosum Treatment

Patient: Male, 83-year-old

Final Diagnosis: Pyoderma gangrenosum

Symptoms: Infection

Medication: —

Clinical Procedure: Negative pressure wound therapy

Specialty: Dermatology • Geriatrics • Palliative Medicine • Surgery

[CME: Gout Ulcer: An Underrecognized Cause of Leg Ulcer and Its Most Common Differential Diagnosis]

CME: Gout Ulcer: An Underrecognized Cause of Leg Ulcer and Its Most Common Differential Diagnosis Abstract. In addition to the differential diagnosis of the leg ulcer, an entity hardly mentioned in the literature is considered, namely the gout ulcer. On the basis of a case study, newer forms of diagnosis and their significance in case of suspicion of gout ulcer are discussed.

Biologics and immunoglobulins in the treatment of pyoderma gangrenosum - analysis of 52 patients

BACKGROUND AND OBJECTIVES

Corticosteroids and cyclosporine A are frequently ineffective as first-line therapies in the treatment of pyoderma gangrenosum (PG) and associated with a number of adverse effects. The objective of the present study was to analyze the effectiveness and safety of biologics and intravenous immunoglobulins (IVIGs).

PATIENTS AND METHODS

Retrospective, dual-center cohort study analyzing the treatment outcome in patients with PG who received biologics and IVIGs.

RESULTS

Fifty-two patients (mean age: 58.4 years) with 75 wound episodes (mean wound size: 53.2 cm²) were included in the study. Overall, 92.3 % of patients initially received corticosteroids (CSs; 48/52); 51.9 % cyclosporine A (CSA; 27/52). In 275 therapeutic attempts, complete remission or improvement were achieved in 63.6 % (21/33) of patients on infliximab; 57.1 % (16/28) on adalimumab; 71.4 % (5/7) on etanercept; 66.6 % (6/9) on ustekinumab and 66.7 % (10/15) of patients who were given IVIGs. That figure was 48.8 % (38/78) for those treated with CSs and 20.0 % (7/35) for individuals on CSA. On average, adverse events occurred in 18.5 % (15/81) of cases treated with biologics in 20 % (3/15) of patients receiving IVIGs, in 40 % (14/35) of individuals on CSA and in 10.4 % of those treated with CSs (5/48).

CONCLUSIONS

The present retrospective analysis suggests that both biologics - especially TNFα antagonists - and IVIGs are well-tolerated and safe options in the treatment of PG. Data from prospective comparative studies would be highly desirable.

The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum

BACKGROUND

The lack of objective diagnostic criteria renders pyoderma gangrenosum (PG) a diagnosis of exclusion. The diagnostic approaches proposed to date have not been systematically evaluated. Thus, PG remains a challenging and frequently misdiagnosed disorder.

OBJECTIVES

To develop and assess a comprehensive, yet clinically practicable, sensitive diagnostic scoring system for PG.

METHODS

Clinical history and images of a total of 60 participants with previously confirmed PG located on the lower extremity and a control cohort of 50 patients with venous leg ulcers were retrospectively evaluated by expert teams at two tertiary dermatological centres specializing in wound care using a newly developed diagnostic scoring system composed of 10 criteria.

RESULTS

The three major diagnostic criteria are rapidly progressing disease, assessment of relevant differential diagnoses and a reddish-violaceous wound border (prevalent in 98% of patients with PG). Minor criteria (evident in 61-95% of patients with PG) include amelioration by immunosuppressant drugs, characteristically irregular shape of ulceration, extreme pain > 4/10 on a visual analogue scale and localization of lesion at the site of the trauma. Three additional criteria (observed in up to 60% of patients with PG) encompass suppurative inflammation in histopathology, undermined wound borders and systemic disease associated. A total score value of 10 points or higher indicates a high likelihood of PG and differentiates PG from venous leg ulcers. The initial letters of the above-listed criteria form the acronym PARACELSUS.

CONCLUSIONS

The PARACELSUS score represents a novel, easily implementable, effective and sensitive diagnostic tool for PG.

Pyoderma gangrenosum: a review of pathogenesis and treatment

INTRODUCTION

Pyoderma gangrenosum (PG) is a complex neutrophilic dermatosis that can occur as an idiopathic disease, in association with systemic conditions such as inflammatory bowel disease, as part of an inherited inflammatory syndrome. It can be challenging to treat, as it occurs in a wide variety of clinical settings and there is a lack of a standardized treatment approach. The main limitations to treatment have been an incomplete understanding of the pathogenesis. However, recent advances have been made in understanding the pathogenesis of this condition, and PG is now considered an autoinflammatory disease process. Areas covered: This review discusses the newest studies that further define our understanding of this disease and the relevant literature on treatment options for pyoderma gangrenosum. Expert commentary: The presence of abnormal neutrophils and T-cells lead to immune dysregulation, leading to lesions of PG. Increased levels of inflammatory mediators including IL-1β, IL-8, IL-17, and TNF-α contribute to the development of the disease but there are still several unknown factors, including the trigger for immune dysregulation and additional contributory components of the immune system. We provide our approach to the management of PG lesions, which involves a multi-faceted approach including wound care, topical therapy, and systemic medications in most cases.

Drug management of neutrophilic dermatoses

INTRODUCTION

Neutrophilic dermatoses are a heterogenous group of chronic, cutaneous inflammatory conditions characterized by the accumulation of neutrophils in the skin and by systemic inflammation. Neutrophilic dermatoses can be idiopathic or associated with other inflammatory or systemic diseases, including the group of the hereditary, autoinflammatory syndromes. Clinical management is challenging, due to limited clinical evidence and lack of clinical practice guidelines. Areas covered: This review provides an overview of current therapeutic management of the three prototypical neutrophilic dermatoses, aseptic pustulosis of the folds, Sweet syndrome and pyoderma gangrenosum. In addition, we describe innovative, pathogenesis-oriented treatment approaches, which are based on recent advances in the pathophysiology of neutrophilic dermatoses and autoinflammatory syndromes. The increasing role of the IL-1 cytokine family in initiating neutrophilic inflammation in both idiopathic and syndromic disease opened the way for the use of targeted biological treatment. Another promising treatment strategy is aimed at blocking downstream effector cytokines, such as IL12/23 and IL-17, involved in the autoinflammatory immune cascade. Expert commentary: In chronic-recurrent and syndromic cases of neutrophilic dermatoses, there is an unmet clinical need for long-term, continuous disease control. Future controlled clinical studies will optimize the use of targeted-biological agents in sequential or combination treatment strategies.

[Pyoderma gangrenosum]

Pyoderma gangrenosum (PG) is an ulcerating, neutrophilic dermatosis of unknown etiology. Clinical appearance is characterized by sudden onset of sterile pustules that rapidly develop into very painful ulcerations with violaceous, undermined borders. Due to the lack of specific diagnostic and therapeutic markers, PG is a diagnosis of exclusion. An association with further diseases such as chronic inflammatory bowel disease, rheumatoid arthritis, diabetes, neoplasms, or metabolic syndrome exists in over 50 % of cases. Treatment of PG consists of suppression of inflammatory disease activity, treatment of associated morbidities, promotion of wound healing, and pain relief. Recommended first-line treatment consists of systemic glucocorticosteroids and additional or alternatively cyclosporine. A controlled trial on infliximab in PG points to efficacy of TNF-alpha antagonists. Due to chronicity, frequent recurrences, and often complicated courses, treatment with good tolerability is important.